New England Life Insurance Company

New England Life Insurance Company

A MetLife Affiliate

RHODE ISLAND BASIC HEALTH BENEFIT PLAN

SUMMARY DESCRIPTION

We pay for medical expenses that you or any of your dependents incur while insured. These expenses must be incurred to diagnose or treat a sickness or an injury. Benefits are payable subject to the Limitations and all other provisions of the Group Policy.

BENEFITS

After the co-insurance and co-payment have been satisfied, we pay the expenses for covered charges. The amount we pay is based on the usual and customary charge for the treatment, service or supply in the locality where furnished. The Schedule of Insurance shows the amount we pay.

SCHEDULE OF INSURANCE

After any applicable co-payment benefits are payable in accordance with the following:

Co Insurance:PPO (In-Network)Non-PPO (Out-of-Network)

Unless otherwise noted,

the benefit payable after the

co-payment is:100% of covered charges60% of covered charges

Preferred Provider (PPO):A provider of medical services or supplies that has contracted with us to provide care to you and your dependents. Preferred Providers have agreed to standards relating to their fees and the appropriateness of the medical care they deliver. (We will give you a list of Preferred Providers and we will update the list when necessary.)

COVERED CHARGES

(1)The basic health benefit plan includes coverage for the following services:

(a)Physician Office Outpatient Services Requiring Co-Payment. The following visits to the office of a physician or other qualified health care practitioner participating in the health benefit plan shall be covered at a co-payment of fifteen dollars ($15) per visit:

(i)primary care physician office visits;

(ii)specialty physician office visits;

(iii)physical examination visits;

(iv)eye examination service visits. Covered visits shall be limited to once every two years;

(v)allergy or dermatology service visits;

(vi)well baby care;

(vii)chiropractic services. Covered visits shall be limited to six (6) per calendar year;

(viii)podiatric services; and

(ix)speech, occupational, physical, cardiac/pulmonary therapy or rehabilitation.

(b)Office and Other Outpatient Services Not Requiring Co-Payment. Visits to the offices of physicians or other qualified health care practitioners or facilities for the following services shall be covered and shall have no co-payment:

(i)pregnancy care, including pre-natal and post-natal care; and

(ii)diagnostic x-rays, laboratory tests and therapeutic treatment.

(2)Emergency, Emergent and Urgent Care. The following services shall be covered at the co-payment rate indicated:

(a)Emergency Room Care, fifty dollar ($50) co-payment per visit. Co-payment shall be waived if admission is required.

(b)Ambulance Services, twenty five dollar ($25) co-payment per occurrence. Air Ambulance and municipal rescue unit services may be covered at the discretion of the carrier. Air ambulance services may require pre-authorization by the health benefit plan.

(c)Urgent Care Centers, co-payment of twenty five dollars ($25) per occurrence.

(3)Inpatient Services, excluding mental health and substance abuse. The following inpatient services shall be covered and there shall be no co-payment:

(a)hospital services, unlimited days in a semi-private room;

(b)inpatient physician services;

(c)surgical and related services; and

(d)organ and tissue transplants.